REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
October 21, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
End
RECOMMENDATION(S)
Recommendation
Accept and approve the establishment or revisions and report of the review and certification of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachment A through K:
1. Mother-Baby Unit Policy and Procedure Manual
2. Pediatric Unit 3 Policy and Procedure Manual
3. Revenue Cycle Policy and Procedure Manual
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost) Revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all Manuals are reviewed and revised, as necessary, a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The Manuals are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals will improve County government operations and provide for the safety, health, and social service needs of County residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Mother-Baby Unit Policy and Procedures Manual (Mother-Baby Manual) contains policies and procedures regarding unit organization, function and guidelines in the provision of high quality and safe patient care practices. The Mother-Baby Manual contains 16 policies, of which six have major revisions, two were deleted, two were moved to the Maternal Child Health Policy and Procedure Manual (MCH Manual), three and the table of contents have minor revisions, and three were reviewed with no recommended changes.
The Mother-Baby Unit completed the 2024-2025 review of the Mother-Baby Manual and recommends the revisions summarized in Attachment A. Update of this manual is certified in Attachment B.
The six policies with major revisions consist of the following:
• Policy No. 201.01 Issue 7, Admission Criteria to the Mother-Baby Unit - Updated the admission guidelines for pregnant patients, patients being readmitted, and criteria for admission and transfer to the Mother-Baby Unit.
• Policy No. 201.03 Issue 6, Assessment and Reassessment of the Newborn - Removed the section referring to Licensed Vocational Nurses (LVN), as no LVNs are currently employed in Mother-Baby Unit. Streamlined the newborn head-to-toe assessment guidelines Updates documentation to reflect current practices
• Policy No. 201.04 Issue 6, Assessment and Reassessment of the Postpartum Patient - Removed the section referring to Licensed Vocational Nurses. Removed outdated or duplicate information and provided a reference to the policy. Streamlined the assessment and reassessment guidelines.
• Policy No. 201.05 Issue 6, Admission of the Transitioning Newborn - Deleted reference to the location of newborn transition and updated guideline. Simplified wording, removed duplicate information, and provided a reference to the policy containing the detailed guidelines. Removed the specific timeframe for newborn bathing to align with current recommended practice.
• Policy No. 202.00 Issue 4, Breastfeeding Supplementation: Alternative Methods - Updated grammar. Updated the supplementation guidelines and discharge documentation to align with current practice.
• Policy No. 221.00 Issue 2, Transcutaneous Bilimeter: Simplified the language and updated screening contraindications and documentation to align with current guidelines.
The two policies that were moved to the MCH Manual consist of the following:
• Policy No. 204.01 Issue 4, Deep Vein Thrombosis: Monitoring and Prevention - This policy was moved from the Mother Baby Manual and added to the Maternal Child Manual as Policy No. 5600.
• Policy No. 219.01 Issue 7, Sepsis: Neonatal - This policy was moved from the Mother Baby Manual and added to the Maternal Child Manual as Policy No. 5500 issue 1.
The two policies that were deleted consist of the following:
• Policy No. 204.04 Issue 5, Duramorph Anesthesia: Postoperative Management - Duramorph Anesthesia is no longer utilized for postpartum patients.
• Policy No. 205.00 Issue 2, Gastric Lavage and Gavage Feeding - No longer an evidenced based practice at ARMC.
The three policies and the table of contents that contain minor revisions consist of minor grammatical corrections and specifications of acronyms.
The Pediatric Unit 3 North Policy and Procedures Manual (Pediatric Manual) contains policies and procedures regarding unit organization, function and guidelines in the provision of high quality and safe patient care practices. The Pediatric Manual contains 11 policies, of which seven policies and the table of contents have minor revisions, two policies were reviewed with no recommended changes, and two policies were deleted.
The Pediatric Unit 3 North completed the 2024-2025 review of the Pediatric Manual and recommends the revisions summarized in Attachment C. Update of this manual is certified in Attachment D.
The two policies that were deleted consist of the following:
• Policy No. 283.00, PEDS Nasal Aspirator Use - Delete. It is a basic fundamental nursing ability to provide safe and effective patient care which does not need to be separately specified in a policy.
• Policy No. 284.00, PEDS Skeletal Pin Care - Delete. No longer part of the service.
The seven policies with minor revisions consist of minor grammatical corrections and specifications of acronyms.
The Department of Revenue Cycle Policy and Procedure Manual (Revenue Manual) contain policies and procedures that define the rules, standards, and procedures that ensure ARMC accurately captures and charges for billable services provided in compliance with regulations and payer contracts. The Revenue Manual is a new manual and contains a total of four policies.
The new Department of Revenue Cycle policies are summarized in Attachment E. Certification of the policies and procedures for the manual is in Attachment F.
The policies in the new Revenue Manual, included in Attachment G through J, consist of the following:
• Policy No. 200.00 V1, Revenue Integrity Mission & Goals - The Revenue Integrity unit's mission is to maximize revenue while ensuring compliance with billing regulations and accuracy in charging. It aims to optimize the Revenue Cycle by identifying and preventing errors, inefficiencies, and discrepancies that could result in lost revenue or regulatory issues.
• Policy No. 201.00 V1, Surgery Level Classification - Provides clear criteria for classifying surgical procedures from Level 1 to Level 5 based on complexity and resource needs. It ensures consistent classification, accurate billing, and proper resource allocation by surgical teams.
• Policy No. 202.00 V1, Wasted Implant Charging - Provides guidance to charge for wasted implants if the vendor invoices for them and will not accept returns. This ensures accurate billing, compliance, and transparency in implant usage and costs. Billable implants must be charged using appropriate current procedural terminology/ healthcare common procedure coding system (CPT/HCPCS) codes, while non-billable items remain non-billable regardless of the department in which they are used.
• Policy No. 203.00 V1, Charge Reconciliation - ARMC requires each department to assign staff responsible for daily revenue reconciliation. This ensures timely and accurate charge capture, proper identification of expected revenue, and detailed tracking of revenue volumes to support ARMC's financial health.
On October 7, 2025 (Item No. 8), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment K.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on September 25, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on September 26, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on September 30, 2025.